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How to improve outcome in elderly patients with hip fracture? : The effect of comprehensive geriatric care in treatment of elderly patients with hip fracture and factors associated with adverse outcome after hip fracture.

(2016)Lowijs, S.N.

Introduction: The number of elderly people will rise, as a result the number of hip fractures will increase as well. Hip fracture in elderly is associated with functional decline and poor overall outcomes. The aim of this study is to profile the population elderly patients admitted with hip fracture in Isala Hospital, to examine the effect of comprehensive geriatric care on outcome and to identify predictive factors for mortality, length of stay and functional decline.
Methods: A descriptive cohort study was performed using data retrospectively and prospectively registered in Isala. The retrospective cohort comprised 291 patients and the prospective cohort 286 patients. Patients in the retrospective cohort were treated by surgeon. Patients in the prospective cohort were screened for frailty, when a patients was considered frail the geriatrician was supervisor in the treatment and end responsible during admission. In non-frail patients the surgeon was supervisor. Multiple regression analyses were used to examine the effect of comprehensive geriatric care on length of stay, as well as to identify predictive factors for length of stay. Multiple logistic regression analyses were used to investigate the effect of comprehensive geriatric care on 30-day mortality, delirium and other outcome variables, as well as to identify predictive factors for 30-day mortality and functional decline.
Results: Length of stay was 21% shorter in the prospective cohort than in the retrospective cohort after adjusting for baseline characteristics. The proportion delirium was lower in the prospective group than in the retrospective group, even after adjusting for baseline characteristics (OR = 0.58). Multiple logistic regression analysis showed that the number of comorbidities (OR = 1.97), anemia at admission (OR = 2.60), (hemi)arthroplasty as operation technique (OR = 2.77) and age (OR = 1.09) were independent risk factors significantly predicting 30-day mortality. Multiple logistic regression analysis revealed that age (OR = 1.18), polypharmacy (OR = 13.31), frail according to screening questions (OR = 4.73) and having a neurodegenerative disease (OR = 54.15) were predictive factors for functional decline. Patients with a neurodegenerative disease did have a 37% shorter length of stay, patients with a 10 hours delay till surgery a 10% longer length of stay and patients with a delirium during admission a 23% longer length of stay.
Conclusions: Comprehensive geriatric care resulted in a 21% decrease in length of stay and 10% less delirium. It is likely that length of stay could decrease further if every patient receives comprehensive geriatric care. Anemia, age, the number of comorbidities, surgery technique, a neurodegenerative disease, frailty, polypharmacy and delirium are predictive factors for an adverse outcome after hip fracture. Comprehensive geriatric care might make it possible to identify patients at high-risk for adverse outcome early during admissions and thereby improve treatment and possibly the outcome in elderly patients with hip fracture